Lecture 48 April 17th-endocrine (extra Class)

1DDX: LECTURE 48 – APRIL 17TH, 2007 ENDOCRINE SYSTEM Case review: the questions on the test will be like this. Cases are from the previous note packages (title highlighted in notes). Hypothalamus and pituitary: CASE #1 A 55 year old man presents at your clinic complaining of increasingly severe headaches over the past 6 months. He’s also had trouble with his eyes recently and a decreased sex drive. He wants to know if it’s “just his age” and if there’s anything he can do to “forestall the inevitable”? Could it be just his age? “Severe”: what does this mean? The other symptoms could be attributed to the effects of cortisol and stress. Dysglycemia or diabetes? Atherosclerosis? (decreased sex drive) Could be stress Concern: it is recent, and there is a severe symptom. Pituitary growth? Prolactinoma? Suppresses FSH/LH, common in alcoholism. Case #2 A 35-year old female presents at your clinic for weight loss techniques. She also complains of fatigue and no menstrual period for the last 4 months. On ROS she notes bad headaches, and “dizziness”. DDXs: Pregnancy? Hypothyroidism? Anorexia? Weight loss, fatigue: will see these everywhere. No menstrual period. Anorexia: May rule in. Hypothyroid? Uncommon effect, and will see menorrhagia first: rule out. Prolactinoma? M/C endocrine tumour, but in general population, rare. Cushings? Can’t rule in or out with info we have. Dysglycemia? Could be related to digestive problems. Emotional stress? We look at the vitals now: does this change anything? Low temperature (35.8, BP 145/90 (high), RR: 12 (a little low), pulse 60 (low) Pituitary? Won’t see this often, but good to keep in mind. Need more information with headaches and dizziness: these are non-specific symptoms. Are they migraines, sinus headaches… Renal? (don’t start adding in new DDXs at this point: go back to list. What have we missed?) Could stress cause high blood pressure? The blood pressure looks like it is trying to compensate for other things. Acromegaly? There are a number of endocrine system involved: this is a good thing to consider (we haven’t seen physical picture of patient: we don’t need this for this case.) Sheehan’s syndrome? This is a pan-pituitary condition. She is overweight (assume there is a weight issue), fatigue (adrenals or thyroid), no menstrual period (FSH, LH involved), headaches, dizziness (common for pituitary conditions). Key point is high blood pressure: see this when there are so many systems off and the body is trying to compensate somehow! If it were a single system, it wouldn’t affect the blood in the same way. Another system will compensate successfully and you won’t see the blood pressure increase. This is a fairly specific red-flag. CASE #3 27 year old female doctoral student presents t your clinic for a milky discharge from her nipples. Her thesis defence is next month and she’s worried she’s worried she might be pregnant. She’s been in a new relationship for the past 3 months and missed 2 days of her birth control pill a few weeks ago. Current medications in clued Synthroid and Amitriptyline (for mild depression) for the past 3 years, and occasionally ½ an Ativan for sleep. Adenoma of pituitary? Liver problems? (metabolizes estrogen) DDX LECTURE 48, APRIL 17TH, 2007 – PAGE 1

What can cause galactorrea? galactinoma, liver dysfunction, sexual intercourse, high stress, cancer (screen for this d/t discharge, but unlikely), TCAs and other meds, pregnancy, birth control pills. Diagnosis: hypergalactinemia THYROID CASE #1: A 65 yeear old woman presents in your office complaining of a painful, swollen throat, hoarseness, diarrhea, breathlessness, and heart palpitations which she attributes to anxiety. On physical exam, she is warm and sweaty ot the touch, and has a swollen thyroid with a palpable bruit. Pulse >200, RR=30 (assume this is an acute) What are the systems you would consider? Hyperthyroid, compression of Vagus nerve (diarrhea, hoarseness), initial phase of Hashimoto’s? Could it be pituitary/hypothalamus? (probably not: rule out). Adrenal crisis? This is a classic thyroid storm. Also could be sub-acute thyroiditis. DDX hyperthyroid from thyroid storm: hyperthyroid is insidious, thyroid storm is immediate. DDX multinodular. CASE #2 A 24 year old woman presents in your office for general health improvement” and weight loss strategies. She describes herself as “always tired”, constipated, and has trouble losing weight. On POS, she notes that she is generally chillier than other around her, has heavy periods, leg cramps and carpal tunnel syndrome. Pulse = 60, RR = 12, BP 140/88, temp = 36.3 Bloodwork 6 months ago shows high triglycerides. Rule out multinodular. Classic hypothyroid symptoms. What are the DDXs? Is the on Synthroid and still has these symptoms? Still hypothyroid. Could be depression (first 2 sentences), or reaction to anti-depressants. She has heavy periods: what else do we need to rule out with this? (Change in menses is a red flag) Thyroid can disrupt it. Fibroids or endometriosis? Need to rule out. Calcium dysregulation due to digestive issue? Carpal tunnel syndrome? Is this a red herring, or does it have something to do with the case? What does she mean by ‘carpal tunnel’? Is this a true diagnosis, or does she just have tingling in her fingers that she has called this? Hashimotos and myxedema? Could just be hypothyroid, and she carries kids around all day. Aspertame has also been established as a big cause of carpal tunnel Type 2 diabetes? Hypothyroid causes high triglycerides. CASE #3 A 32-year old man presents in your office with fatigue of 6 months duration, and recent shortness of breath. He has been trying to eat “healthier”, including lots of vegetables, fruit and seafood, but his appetite hasn’t been great and he feels he has lost weight. On exam he has several swollen cervical lymph nodes. One in particular is large and hard on palpation. On ROS, he notes extensive dental imaging and surgery in the past 18 months. Lots of things that can affect the thyroid: imaging, Tumour, cancer Think about why all of the pieces in the case have been thrown in. Tuberculosis? HIV? Age demographic, cervical lymph nodes, weight loss, fatigue, SOB. Page 5 SECONDARY ADRENAL INSUFFICIENCY Addisons at the pituitary level ADRENAL VIRILISM Mild cases, might only see hirsutism. (M/C condition causing hirsutism? PCOS) In men, won’t see much. Slide should say that DEX might produce signs of Addison’s, NOT Cushings DHEA because androgens being produced, urinary cortisol is diminished because you are missig the enzymes, so the production is lowered. Dexamethasone; think of this as cortisol stimulant as well as androgen-suppressant. MC presentation is trouble getting pregnant, hirsuitism, disturbed menses, find high testosterone on blood test. DDX LECTURE 48, APRIL 17TH, 2007 – PAGE 2

CUSHING’S SYNDROME ACTH independent: the tumour itself is secreting, not due to feedback from adrenals. SCC = small cell carcinoma: the one type of non-adrenal tumour that produces ACTH. Only one other condition discussed that has pronounced psychiatric disturbances: hyperthyroidism Hard to DDX regular obesity: but fat is in jowels, cheeks. May obscure ears from front. First signs of hypercortisol (labs)? No peaks and valleys. DDX obesity: cortisol is minimally increased. Dexamethasone used diagnostically. Decreases ACTH. Tumour? ACTH won’t be suppressed. Treatment: why potassium and high protein? You are in a hypermetabolic state and you are using up protein, breaking it down. This state tends to drive digestion  diarrhea  loss of potassium. HYPERALDOSTERONISM Main symptom is hypertension (but this is a rare case: not every case of HT is Conn’s!) Low potassium is causing a lot of the symptoms. What other condition to consider based on symptoms? Diabetes insipidus or mellitus. SECONDARY HYPERALDOSTERONISM How do we see increase aldosterone outside of the adrenals? (see list) Look at where things are metabolized… ADRENAL ADENOMAS ADRENAL CARCINOMAS Most are functional. This is unusual: usually tumours less hormonally active if more differentiated. Why low survival? Metastases. Adrenals are a target for metastases d/t location (blood flow, lymphatic towards kidneys). ADRENAL MEDULLA AND PARATHYROIDS 24 hour urine VMA useful for DDX of pheochromocytoma Why hypothoidism? Compensatory output of increased epinephrine to counteract low BMR. See list of things that increase catecholamines. PHEOCHROMOCYTOMA Less than 0.1% of all HT cases (remember this) DDX thyroid storm, onset of MI, aneurysm, acute hypertensive attack (not that uncommon-esp. in elderly. Can have controlled HT, but have crisis due to illness, surgery, emotional crisis) Catecholamine cardiomyopathy: why do you get necrosis first? Due to sustained elevated BMR and chronic low 02. NEUROBLASTOMA M/C area to grow is abdominal. Easy to see because it grows in first 3 years of life. Eventually causes a lot of bone pain. Usually diagnoses on signs and symptoms: labs are only slightly abnormal. PARATHYROID GLANDS Lesion is at level of parathyroid: PTH levels will be high in relation to Ca++ Not primary and “secondary” but “pseudo” meaning target organ insensitivity COOH terminal endings get this in some neoblasms and in kidney failure. NH2 terminal ending: (see notes) *Decreased PTH=hyperthyroidism. Why? Increased BMR, increase both anabolic and catabolic activity. Calcium goes up, PTH goes down. DiGeorge’s Syndrome: parathyroid agenesis High calcium supplementation in any form will decrease levels of PTH. Phosphates increase the level (bind calcium?) HYPOPARATHYROIDISM Mild tingling to severe muscle cramps: could see this in Hashimoto’s myxedema In idiopathic hypoparathyroidism: may have auto-immune component: see antibodies. DDX LECTURE 48, APRIL 17TH, 2007 – PAGE 3

PRIMARY HYPERPARATHYROIDISM Again, carcinomas are generally not functioning, but this one is, like in adrenal virilizing syndrome. Recurrence common: can occur in other parathyroid glands (4)

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